Thoughts on Osteoarthritis in Younger People

Key points from the journal article “Hip and Knee Osteoarthritis Affects Younger People, Too” – JOSPT February 2017

1.osteoarthritis in younger peopleOA is no longer considered a degenerative disease of “wear and tear” affecting joint cartilage and bone. It is now understood to represent total joint failure, with a prominent inflammatory component. Most recently, the contribution of meta-inflammation has also been identified, whereby body fat releases inflammatory mediators (cytokines and adipokines) that contribute to joint damage. Within this new paradigm, overweight and obesity contribute to OA through both biomechanical (increased joint load) AND inflammatory mechanisms…

2.The most recent GBD data show that in this younger age group (15-49 years old) OA accounted for 2.4 million years lived with disability worldwide in 2013. Years lived with disability due to high body mass index have also increased markedly for males and females, age 15-49 years since 1990, emphasizing the potential contribution of rising obesity levels to global OA burden among younger people.

3.Studies of the projected OA burden also highlight anticipated growth in OA for younger age groups. In Canada, an increased prevalence of arthritis among women aged 35-44 years, and among both sexes aged 45-54 years, has been predicted by the year 2021. In Australia , the number of people with OA aged less than 55 years has been projected to increase by 20% over the next 15 years, due to population growth alone.

4.Younger populations with OA represent a new public health issue, given that these individuals will likely live with OA for a longer time than did previous generations.osteoarthritis in younger people

5.The USA and Canada have reported significant growth in rates of THR and TKR performed in younger people. Increase in rate of primary THR in USA (30%)  and Ontario, Canada (60%). It is anticipated that 52% of all primary THR will be performed for younger patients, <65 years old, by 2030.

6.Work related costs of OA in younger populations cannot be overlooked. Leaving the workforce early due to arthritis is estimated to cost Australia over $7 Billion annually in lost gross domestic product and this is projected to rise to $9.4 billion by 2030.

7. From a societal perspective, the financial impacts of early exit from workforce include lost productivity and taxation revenue and greater need for government support payments.

8.Though high-intensity sporting activity has been reported as a risk factor for hip OA, whether this is related to acute injury or repetitive joint loading is unclear. The link between injury and subsequent OA is less well established for the hip vs the knee.

9. Hip Dysplasia is associated with development of hip OA in younger people. FAI is a common cause of hip and groin pain in young and middle-aged active people and these people often present with intra-articular changes consistent with early hip OA. People with CAMs have an almost 10-fold higher risk of progression to end-stage hip OA within 5-20 years. Longitudinal research to identify potential modifying factors is currently underway.

10.Hip OA and knee OA are associated with pain and a range of physical impairments that can substantially impact quality of life, particularly for younger people, who may need to manage their OA alongside family and work commitments. A recent study involving 147 people with hip or knee OA aged 20-55 years found that this group had markedly impaired health-related quality of life compared with age- and sex-matched population norms. Participants reported an average 35% reduction in health-related-quality-of-life scores and the overall prevalence of high or very high psychological distress was 4 times higher that for the national population of similar age.

11.People with hip chondral pathology likely associated with early OA have also demonstrated worse quality of life than matched healthy controls.

12.It is evident that hip and knee OA can have a broad range of impacts on younger individuals (particularly with regard to work-, sporting-, and parenting-related tasks) that could undoubtedly contribute to impaired psychosocial well-being.

13.Osteoarthritis in younger people affects their participation in labor forceOf particular relevance to younger people is the impact of OA on the ability to work and maintain employment. Individuals with OA have 64% increased risk of being out of the labor force AND, in turn, being out of the workforce due to arthritis is associated with short and longer-term financial consequences.

14.Work related impacts of OA among younger people include increased risk of sick leave, substantial workplace limitations and a higher likelihood of work loss due to illness or disability.

15.There is a clear need to develop consensus-based recommendations for assessment and treatment of early OA in younger people.

16.There are no published clinical guidelines for treatment of hip and knee OA that are specific to younger people. They are derived from current research on older people and include these 3 approaches: 1. Education and access to OA-related information, 2. Individually-prescribed exercise therapy and/or aerobic fitness training, 3. Weight control or weight loss.

17.In absence of disease-modifying interventions, efforts to control/improve symptoms and delay OA progression are key management priorities.

18.Given the graded relationship between physical activity levels and function, strategies to increase physical activity are important.

19.Joint Protection Methods for osteoarthritis in younger people Given the work-related impacts of OA, treatment should also include advice on how to manage work tasks in the context of OA symptoms and functional limitations. Strategies should include joint protection methods, fatigue management, modification or work duties, ergonomic adaptations, and flexible work arrangements.

20.Given the work-related impacts of OA, treatment should also include advice on how to manage work tasks in the context of OA symptoms and functional limitations. Strategies should include joint protection methods, fatigue management, modification or work duties, ergonomic adaptations, and flexible work arrangements.

21.Some studies have shown increased revision rates in younger patients compared to older patients. Decisions regarding joint replacement surgery are challenging for younger patients with OA and their treating clinicians given the potential need for revision surgery (or multiple revisions) over a younger person’s lifetime.

22.Rising rates of obesity and sports injuries are concerning and may signal a future surge in OA incidence among younger people.

23.Nonpharmacological approaches are core strategies for the management of hip and knee OA in younger people. When these non-pharmacological and pharmacological strategies are exhausted or no longer effective, referral for joint-conserving or joint replacement surgery should be considered.

I think we can all agree that OA significantly affects younger people in multiple ways including physically, emotionally, financially, within their occupation and in their future health overall.  In this day and age of 2017, we still don’t really have a clear consensus on what to do about it.  Basically the best current advice is to get moving and manage weight appropriately. I believe this is great advice, however as the individual progresses in their capsular pattern of restriction, increased intra-articular pressure and increased pain, they won’t be able to or be interested in getting moving or exercise due to the significant increase in their pain levels. Most people are motivated to exercise if it helps them feel better, but when exercise starts to hurt, they stop exercising even if it’s good for them. I believe we need to provide care to individuals to improve and maintain capsular mobility for as long as possible as the primary goal. If this occurs, the individual has a much greater chance of achieving their exercise and weight loss goals.

What could happen if we could convince younger people, with early onset hip OA, to start “brushing and flossing” their hips BEFORE they get a “cavity” in their hip? We know that maintaining capsular mobility and functional strength around the hip joint helps people with or without OA to experience less pain, greater functionality and greater quality of life. Let’s create programs that educate younger patients on how to prevent capsular restrictions, treat them when they have them and maintain or enhance functional strength around their lumbopelvic and hip regions!